Fax request for medical records 2025

1. Click ‘Get Form’ to open the fax request for medical records in our editor.
2. Begin by filling in the recipient's details. Specify who will receive the records, including their name, address, city, state, zip code, phone number, and fax number.
3. Complete the Patient Authorization section. Enter your name, date of birth, any other names you may have used, and the last four digits of your Social Security Number.
4. Indicate the dates of service you wish to release or select 'the entire Medical Record' if applicable.
5. Provide a reason for the release of information. This is mandatory for processing your request.
6. Review any restrictions on the information being shared and initial next to any exclusions that apply.
7. Sign and date the authorization form at the bottom. If someone else is completing this form on your behalf, ensure they provide their details and check the appropriate box.

Start using our platform today to easily fill out your fax request for medical records!